Advocacy Blog

TAKE CARE: Advocacy Blog Series

Accumulator Adjustment Programs

We’re excited to present a new advocacy blog series meant to help you take care when it comes to important arthritis health care and coverage issues. Over the next two months, we’ll post a blog every other week to help patients like you know what access issues we are watching and what you can do about them. This week we’ll tell you about a new policy many pharmacy benefit managers (PBMs) are using called accumulator adjustment programs, which could especially impact people in high deductible health plans. Read on to learn more about these programs and why they are being implemented.

What are accumulator adjustment programs?

Many pharmaceutical manufacturers offer co-pay cards that help cover a patient’s portion of drug costs. Traditionally, PBMs have allowed these co-pay card payments to count toward the deductible required by a patient’s health insurance plan. With an accumulator adjustment program, patients are still allowed to apply the co-pay card benefits to pay for their medications up to the full limit of the cards, but when that limit is met, the patient is required to pay their full deductible before cost-sharing protections kick in.

What does this mean for patients?

It means that when your copayment card limit has been reached, the value on the card will not have counted toward your deductible or annual out-of-pocket maximum. Instead, you will need to pay your full deductible before cost-sharing protections kick in.

Here’s an example: It’s the start of a new health plan year in January and you are on a biologic with a list price of $3,000 a month. You use your copay card at the pharmacy and make a regular copayment at the counter. By the time March arrives, you’ve reached the limit on your copay assistance. As a result, when you go to refill your prescription in April, you will owe $3,000, the full cost of your drug, because the deductible has not yet been paid down.

For patients enrolled in these programs, we want to make sure they understand the elements of the program and are prepared to pay the full cost of their deductible should they exhaust their copayment assistance. As shown in the example above, people on expensive medications like biologics could be affected as early as this month, if they haven’t been already.

Why are PBMs and insurers using these programs?

PBMs and insurers argue that copayment assistance keeps drug costs artificially high by incentivizing patients to use higher-cost, branded drugs when lower-cost drugs are available. If a branded drug costs $100 and there’s a lower-cost alternative available for $50 – but the branded drug offers you a copayment card that covers 90 percent of the drug cost – which are you going to choose?

While this may be a valid argument in many cases, the problem is that for some therapeutic classes – rheumatoid arthritis is a good example – there are no generics or significantly lower-cost alternatives. Whatever the case, patients with chronic diseases who rely on regular access to treatments to stay healthy may be negatively impacted by these programs.

Who is enrolled in these programs?

People most likely to be enrolled in these programs are those in employer-sponsored plans and those in high-deductible health plans (HDHPs) in particular. HDHPs are becoming increasingly common as plans employers and insurers use to help incentivize appropriate health care utilization and to lower costs.

If you have been affected, or think you might be in one of these programs and want to be prepared, what can you do?

Consult your health plan materials or call your insurer to ask questions. If you have been affected by this type of policy and have had to switch to another drug or have been unable to fill your prescription, tell your insurer. We do not believe that insurers want to implement policies that lead to medication nonadherence. But they won’t know unless you tell them.

Tell your employer, too. Your employer may have adopted this program thinking of it as a cost-savings strategy without truly understanding the negative impact it could have on their employees.

Tell us! We want to know about your experience, so we can be better informed when we are advocating for you.

If you are unable to afford your prescription drugs, patient assistance programs may help. Also visit our Access to Care Toolkit for help navigating all aspects of health coverage.

We understand that health care costs continue to be a complex issue for all parts of the health care industry, for employers and for patients themselves. The Arthritis Foundation family wants to be a part of the solution. We are here for you and will continue working diligently to identify solutions that put patients first.